Lack aid? Many counties have only pricey plans

Dec. 26, 2013
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Angel Rivera and his wife, Wilma Rivera, sit with Amada Cantera, right, an insurance agent with Sunshine Life and Health Advisors as the couple tries to purchase health insurance under the Affordable Care Act at the kiosk setup at the Mall of Americas on Dec. 22, 2013, in Miami. / Joe Raedle, Getty Images

by Jayne O'Donnell and Paul Overberg, USA TODAY

by Jayne O'Donnell and Paul Overberg, USA TODAY

More than half of the counties in 34 states using the federal health insurance exchange lack even a bronze plan that's affordable - by the government's own definition - for 40-year-old couples who make just a little too much for financial assistance, a USA TODAY analysis shows.

Many of these counties are in rural, less populous areas that already had limited choice and pricey plans, but many others are heavily populated, such as Bergen County, N.J., and Philadelphia and Milwaukee counties.

More than a third don't offer an affordable plan in the four tiers of coverage known as bronze, silver, gold or platinum for people buying individual plans who are 50 or older and ineligible for subsidies.

Those making more than 400% of the federal poverty limit - $47,780 for an individual or $61,496 for a couple - are ineligible for subsidies to buy insurance.

The USA TODAY analysis looked at whether premiums for the least expensive plan in any of the metal levels was more than 8% of household income. That's similar to the affordability test used by the federal government to determine whether premiums are so expensive consumers aren't required to buy plans under the Affordable Care Act.

The number of people who earn close to the subsidy cutoff and are priced out of affordable coverage may be a small slice of the estimated 4.4 million people buying their own insurance and ineligible for subsidies. But the analysis clearly shows how the sticker shock hitting many in the middle class, including the self-employed and early retirees, isn't just a perception problem. The lack of counties with affordable plans means many middle-class people will either opt out of insurance or pay too much to buy it.

The prices of exchange plans have shocked many shoppers, especially those who had plans canceled because they did not meet the ACA coverage requirements. But experts are not surprised.

"The ACA was not designed to reduce costs or, the law's name notwithstanding, to make health insurance coverage affordable for the vast majority of Americans," says health care consultant Kip Piper, a former government and insurance industry official. "The law uses taxpayer dollars to lower costs for the low-income uninsured but it also increases costs overall and shifts costs within the marketplace."

Along with underscoring how high rates are in many places, the analysis could portend more problems for the health law's troubled rollout. The Congressional Budget Office projected 7 million people would sign up for the law by the end of 2014 and enrollment is already falling several million short of that goal. Insurers need a lot of relatively healthy people to sign up for insurance to make up for the higher cost of insuring the less healthy. Highly subsidized lower-income consumers who haven't had insurance before often weren't getting regular doctors' visits. If many of those making about $50,000 for an individual or about $62,000 in household income for a couple opt out of the new health care system, it will deprive it of some of the counterbalancing effect needed.

Still, about 95% of consumers live in states where the average premiums are below earlier estimates, says Department of Health and Human Services spokeswoman Joanne Peters.

"The new Marketplace is night and day from what consumers faced in the individual market before the health care law, where they could see unlimited out-of-pocket expenses for plans with limited benefits and high deductibles, if they can even get coverage without being denied for a pre-existing condition," says Peters.

Many ACA-compliant plans will cover prescription drugs, routine care for chronic conditions and primary care visits even before deductibles are met, Peters notes.

But those aren't the plans that are affordable to many middle-class individuals buying insurance. In many cases, catastrophic plans - which USA TODAY excluded from its analysis - may be all that's left for consumers on the exchanges. These high-deductible plans are generally only available for consumers under 30, who are least likely to need to use them, but they can also be purchased by people who don't have other affordable options available in their area. These plans generally require consumers to pay all of their medical costs up to a certain amount - often $6,000 or more - although preventive benefits such as physicals have to be covered under the new law.

President Obama said last week that people whose plans were canceled and think the options on the exchanges are too expensive aren't required to buy insurance or can buy a catastrophic plan through what's known as a "hardship exemption." But most people actually do want insurance, says financial counselor and author Karen McCall.

"Every one of those people, if they have any consciousness and aren't totally self-medicating, would prefer to have insurance," says McCall, author of the book Financial Recovery. "You could go a year and not get any benefit of health insurance, but there is a deep emotional need to know that we have proper insurance."

State and federal exchange officials approve the rates health insurers can offer, and plans are then subsidized to levels that make them affordable for those below 400% of the poverty level. Karen Pollitz, a senior fellow at the Kaiser Family Foundation, acknowledges that catastrophic and even bronze plans would be very difficult for many 40 or 50-something consumers to afford with their $5,000-$6,000 annual deductibles.

"Most people don't have that kind of money in the bank, and I think it's going to create problems for people," Pollitz says.

Although premiums are unaffordable in many places now, protections in the law will prevent the massive jumps in premiums that characterized the individual insurance market before the ACA, she says.

Individual policies before had only the "optics of affordability and no dependability," Pollitz says. "What good is protection if it doesn't work when you need it?"